Concussion

Concussion is a mild traumatic brain injury producing transient disturbance of neurological function after biomechanical force.

Loss of consciousness is not required.

Conventional CT and MRI are usually normal because concussion is primarily a functional and microscopic neuronal injury rather than a macroscopic structural lesion.

The typical GCS is 13 to 15, although most uncomplicated concussion patients are GCS 15 by assessment.

Symptoms can affect:

• Cognition
• Balance
• Vision
• Sleep
• Mood
• Headache pathways

The clinical task is first to ensure that the patient does not have a more dangerous structural head injury.

Symptoms include:

• Headache
• Dizziness
• Nausea
• Photophobia
• Phonophobia
• Blurred vision
• Difficulty concentrating
• Slowed thinking
• Memory disturbance
• Fatigue
• Irritability
• Sleep disturbance

There may be:

• Brief loss of consciousness
• Retrograde amnesia
• Anterograde amnesia
• Confusion
• Imbalance

Red flags

Urgent reassessment and usually CT are required with:

• Declining GCS
• Repeated vomiting
• Worsening severe headache
• New focal neurological deficit
• Seizure
• Unequal pupils
• Significant anticoagulant use with concerning injury
• Suspected skull fracture
• Progressive confusion
• Severe behavioural change
• Significant mechanism plus concerning examination

Diagnosis is clinical.

Do not obtain CT simply to diagnose concussion.

CT is used to exclude intracranial haemorrhage or fracture when clinical decision rules and patient factors indicate imaging.

In an adult taking anticoagulants who has a normal neurological examination and a negative initial CT, routine admission solely for repeat imaging is generally unnecessary when the patient remains neurologically stable and reliable follow up exists.

MRI is not routinely required for uncomplicated acute concussion.

Consider MRI or specialist evaluation when:

• Focal deficit persists
• Symptoms are unusually prolonged
• Structural injury remains suspected despite CT
• Another diagnosis is likely

First 24 to 48 hours

Use relative rest, not prolonged complete sensory deprivation.

Allow:

• Light daily activity
• Short walks
• Simple cognitive activity

provided symptoms do not increase substantially.

Most adults should begin gradual return to ordinary activity after approximately 1 to 2 days, rather than remaining completely inactive until every symptom disappears.

Avoid:

• Alcohol
• Driving while attention or reaction time remains impaired
• Contact sport
• Activities with substantial risk of a second head injury

Headache treatment

A practical initial option is:

Paracetamol 1 g orally every 6 to 8 hours as required

maximum 4 g daily in adults without significant hepatic risk.

NSAIDs can be used after clinically important intracranial bleeding has been excluded when there is no other contraindication.

Avoid routine opioids because:

• Sedation interferes with neurological assessment
• Dependence can develop
• They often worsen dizziness and nausea

Return to work and study

Return progressively according to symptom tolerance.

Temporary modifications can include:

• Shorter working hours
• Frequent breaks
• Reduced screen exposure
• Reduced complex multitasking
• Temporary avoidance of driving or safety critical work

Persistent symptoms should trigger targeted assessment for:

• Vestibular dysfunction
• Migraine phenotype
• Cervicogenic headache
• Sleep disorder
• Mood disturbance
• Oculomotor dysfunction

Return to sport

Do not allow same day return to contact sport after suspected concussion.

After return to normal daily function and appropriate clinical clearance, use graded progression:

• Normal daily activity
• Light aerobic exercise
• Moderate activity
• Heavy noncontact exercise
• Full contact practice after medical clearance
• Return to competition

Each stage generally lasts at least 24 hours. If symptoms return, step back to the previous asymptomatic stage.

Persistent symptoms

Most patients improve within days to several weeks.

Symptoms persisting beyond approximately 2 to 4 weeks deserve reassessment rather than repeated instructions simply to rest.

Management should target the dominant deficit.

For example:

• Vestibular rehabilitation for persistent dizziness
• Graded aerobic rehabilitation for exertional intolerance
• Migraine directed therapy for post traumatic migraine
• Sleep intervention for insomnia
• Psychological support where mood or anxiety symptoms contribute